Aetna Golden Medicare Plan. Aetna Golden Choice TM Plan

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1 You must be entitled to Medicare Part A and continue to pay your Part B premium and Part A, if applicable. Coverage is provided through a Medicare Advantage organization with a Medicare contract and benefits, limitations, service areas and premiums are subject to change on January 1 of each year. Aetna Golden Medicare Plan For the Aetna Golden Medicare Plan: You must use network providers except for emergent care or out of area urgent care/renal dialysis. Aetna Golden Choice TM Plan For the Aetna Golden Choice Plan: Higher costs apply for out-of-network services. Precertification, or prior approval of coverage for, certain services is requested. Providers must be licensed and eligible to receive payment under the federal Medicare program. If you are a dual eligible individual (eligible for both Medicare and state Medicaid programs) and have enrolled in an Aetna Medicare Advantage plan, it is important that you present both your Aetna Medicare and state Medicaid id cards when you receive plan services. Some providers do not accept state Medicaid patients and this could impact your out of pocket costs. M0001_7A_70744 ( ) B (8/07)

2 Important Disclosure Information Aetna Golden Medicare Plan, Aetna Golden Choice Plan Note: Medicare Advantage plan requirements govern and supersede any state or general disclosures contained within. Plan of Benefits Covered services include most types of treatment provided by primary care physicians, specialists and hospitals. However, the health plan does exclude and/or include limits on coverage for some services, including but not limited to, cosmetic surgery and experimental procedures. In addition, in order to be covered, all services, including the location (type of facility), duration and costs of services, must be medically necessary as defined below and as determined by Aetna*. The information that follows provides general information regarding Aetna health plans. For a complete description of the benefits available to you, including procedures, exclusions and limitations, refer to your specific plan documents, which may include the Schedule of Benefits, Certificate of Coverage, Group Agreement, Group Insurance Certificate, Group Insurance Policy and any applicable riders and amendments to your plan. Direct Access Ob/Gyn Program This program allows female members to visit any participating obstetrician or gynecologist for a routine well woman exam, including a Pap smear, and for obstetric or gynecologic problems. Obstetricians and gynecologists may also refer a woman directly to other participating providers for covered obstetric or gynecologic services. All health plan preauthorization and coordination requirements continue to apply. If your Ob/Gyn is part of an Independent Practice Association (IPA), a Physician Medical Group (PMG), an Integrated Delivery System (IDS) or a similar organization, your care must be coordinated through the IPA, the PMG or similar organization and the organization may have different referral policies. Health Care Provider Network All hospitals may not be considered participating for all services. Your physician can contact Aetna to identify a participating facility for your specific needs. Certain PCPs are affiliated with integrated delivery systems, independent practice associations ("IPAs") or other provider groups, if you select these PCPs you will generally be referred to specialists and hospitals within that system, association or group ( organization ). However, if your medical needs extend beyond the scope of the affiliated providers, you may request coverage for services provided by nonorganization affiliated network physicians and facilities. In order to be covered, services provided by non-organization affiliated network providers may require prior authorization from Aetna and/or the integrated delivery systems or other provider groups. You should note that other health care providers (e.g. specialists) may be affiliated with other providers through organizations. These organizations or, their affiliated providers may be compensated by Aetna through a capitation arrangement or other global payment method. The organization then pays the treating provider directly through various methods. You should ask your provider how he or she is being compensated for providing health care services to you and if he/she has any financial incentive to control costs. Advance Directives An advance directive is a legal document that states your wishes for medical care. It can help doctors and family members determine your medical treatment if, for some reason, you can t make decisions about it yourself. There are three types of advance directives: Living will spells out the type and extent of care you want to receive. * Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies. 2

3 Durable power of attorney appoints someone you trust to make medical decisions for you. Do-not-resuscitate order states that you don t want to be given CPR if your heart stops or if you stop breathing. You can create an advance directive in several ways: Get an advance medical directive form from a health care professional. Certain laws require health care facilities that receive Medicare and Medicaid funds to ask all patients at the time they are admitted if they have an advance directive. You don t need an advance directive to receive care. But we are required by law to give you the chance to create one. Ask for an advance directive form at state or local offices on aging, bar associations, legal service programs, or your local health department. Work with a lawyer to write an advance directive. Create an advance directive using computer software designed for this purpose. If you have Medicare coverage and aren t satisfied with the way Aetna handles advance medical directives, you can file a complaint with your Medicare State Survey and Certification Agency. Visit for information on specific state agencies. Or call the Medicare phone number at MEDICARE ( ). For the hearing and speech impaired, dial TTY Advanced Directives and Do Not Resuscitate Orders. American Academy of Family Physicians, March (Available at Transplants and Other Complex Conditions Our National Medical Excellence Program and other specialty programs helps you access covered treatment for transplants and certain other complex medical conditions at participating facilities experienced in performing these services. Depending on the terms of your plan of benefits, you may be limited to only those facilities participating in these programs when needing a transplant or other complex condition covered. Note: There are exceptions depending on state and federal Medicare requirements. Prescription Drugs If your plan covers outpatient prescription drugs, your plan may include a preferred drug list (also known as a "drug formulary"). The preferred drug list includes a list of prescription drugs that, depending on your prescription drug benefits plan, are covered on a preferred basis. Many drugs, including many of those listed on the preferred drug list, are subject to rebate arrangements between Aetna and the manufacturer of the drugs. Such rebates are not reflected in and do not reduce the amount you pay to your pharmacy for a prescription drug. In addition, in circumstances where your prescription plan utilizes copayments or coinsurance calculated on a percentage basis or a deductible, your costs may be higher for a preferred drug than they would be for a nonpreferred drug. For information regarding how medications are reviewed and selected for the preferred drug list, please refer to Aetna's website at or the Aetna Medicare Preferred Drug (Formulary) Guide. Printed Aetna Medicare Preferred Drug Guide information will be provided, upon request or if applicable, annually for current members and upon enrollment for new members. Additional information can be obtained by calling Member Services at the toll-free number listed on your ID card. The medications listed on the preferred drug list are subject to change in accordance with applicable state law. Your prescription drug benefit is generally not limited to drugs listed on the preferred drug list. Medications that are not listed on the preferred drug list (nonpreferred or nonformulary drugs) may be covered subject to the limits and exclusions set forth in your plan documents. Covered nonformulary prescription drugs may be subject to higher copayments or coinsurance under some benefit plans. Some prescription drug benefit plans may exclude from coverage certain nonformulary drugs that are not listed on the preferred drug list. If it is medically necessary for you to use such drugs, your physician (or pharmacist in the case of antibiotics and analgesics) may contact Aetna to request coverage as a medical exception. Check your plan documents for details. 3

4 In addition, certain drugs may require precertification or step-therapy before they will be covered under some prescription drug benefit plans. Step-therapy is a different form of precertification which requires a trial of one or more "prerequisite therapy" medications before a "step therapy" medication will be covered. If it is medically necessary for you to use a medication subject to these requirements, your physician can request coverage of such drug as a medical exception. In addition, some benefit plans include a mandatory generic drug cost-sharing requirement. In these plans, you may be required to pay the difference in cost between a covered brand name drug and its generic equivalent in addition to your copayment if you obtain the brand-name drug. Nonprescription drugs and drugs in the Limitations and Exclusions section of the plan documents (received and/or available upon enrollment) are not covered, and medical exceptions are not available for them. Depending on the plan selected, new prescription drugs not yet reviewed for possible addition to the preferred drug list are either available at the highest copay under plans with an "open" formulary, or excluded from coverage unless a medical exception is obtained under plans that use a "closed" formulary. These new drugs may also be subject to precertification or step-therapy. You should consult with your treating physician(s) regarding questions about specific medications. Refer to your plan documents or contact Member Services for information regarding terms, conditions and limitations of coverage. If you use the mail order prescription program of Aetna Rx Home Delivery, LLC, or the Aetna Specialty Pharmacy SM specialty drug program, you will be acquiring these prescriptions through an affiliate of Aetna. Aetna s negotiated charge with Aetna Rx Home Delivery and Aetna Specialty Pharmacy may be higher than their cost of purchasing drugs and providing pharmacy services. For these purposes, Aetna Rx Home Delivery's and Aetna Specialty Pharmacy s cost of purchasing drugs takes into account discounts, credits and other amounts that they may receive from wholesalers, manufacturers, suppliers and distributors. Updates to the Drug Formulary You can obtain formulary information from the Internet at or by calling your Member Services toll-free number. Behavioral Health Network Behavioral health care services are managed by Aetna, except for certain HMO-based health plans in New York that are managed by an independently contracted behavioral health care organization. Aetna and the behavioral health care organization are responsible for, in part, making initial coverage determinations and coordinating referrals to providers. As with other coverage determinations, you may appeal adverse behavioral health care coverage determinations in accordance with the terms of your health plan. The type of behavioral health benefits available to you depends upon the terms of your health plan. If your health plan includes behavioral health services, you may be covered for mental health conditions and/or drug and alcohol abuse services, including inpatient and outpatient services, partial hospitalizations and other behavioral health services. You can determine the type of behavioral health coverage available under the terms of your plan and how to access services by calling the Aetna Member Services number listed on your ID card. If you have an emergency, call 911 or your local emergency hotline, if available. For routine services, you may access covered behavioral health services available under your health plan by the following methods: Call the toll-free Behavioral Health number (where applicable) on your ID card or, if no number is listed, call the Member Services number on your ID card for the appropriate information. Where required by your plan, call your PCP for a referral to the designated behavioral health provider group. When applicable, an employee assistance or student assistance professional may refer you to your designated behavioral health provider group. 4

5 You can access most outpatient therapy services without a referral or pre-authorization. However, you should first consult with Member Services to confirm that any such outpatient therapy services do not require a referral or preauthorization. Behavioral Health Provider Safety Data Available For information regarding our Behavioral Health provider network safety data, please go to and review the quality and patient safety links posted: You may select the quality checks link for details regarding our providers safety reports. Behavioral Health Prevention Programs Aetna Behavioral Health offers two prevention programs for our members: Perinatal Depression Education, Screening and Treatment Referral Program also known as Mom s to Babies Depression Program and Identification and Referral of Adolescent Members Diagnosed With Depression Who Also Have Co-morbid Substance Abuse Needs. For more information on either of these prevention programs and how to use the programs, ask Member Services for the phone number of your local Care Management Center. Claims Payment for Non-Network Providers If your plan provides coverage for services rendered by non-network providers, you should be aware that Aetna determines the allowable fee for a non-network provider by referring to the Original Medicare approved amount, which is the maximum amount that Original Medicare allows a provider to accept. Charges by a non-network provider in excess of the Medicare approved amount will not be covered by Aetna, nor are they the responsibility of the member. You may be responsible for any charges Aetna determines are not covered under your plan, as well as any cost sharing outlined in your plan documents. Technology Review Aetna reviews new medical technologies, behavioral health procedures, pharmaceuticals and devices to determine which one should be covered by our plans. And we even look at new uses for existing technologies to see if they have potential. To review these innovations, we may: Study medical research and scientific evidence on the safety and effectiveness of medical technologies. Consider position statements and clinical practice guidelines from medical and government groups, including the federal Agency for Health care Research and Quality. Seek input from relevant specialists and experts in the technology. Determine whether the technologies are experimental or investigational. You can find out more on new tests and treatments in our Clinical Policy Bulletins. You can find the bulletins at under the Members and Consumers menu. Medically Necessary Medically necessary" means that the service or supply is provided by a physician or other health care provider exercising prudent clinical judgment for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that provision of the service or supply is: In accordance with generally accepted standards of medical practice; and Clinically appropriate in accordance with generally accepted standards of medical practice in terms of type, frequency, extent, site and duration, and considered effective for the illness, injury or disease; and Not primarily for the convenience of you, or for the physician or other health care provider; and Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the illness, injury or disease. 5

6 For these purposes generally accepted standards of medical practice means standards that are based on credible scientific evidence published in peerreviewed medical literature generally recognized by the relevant medical community, or otherwise consistent with physician specialty society recommendations and the views of physicians practicing in relevant clinical areas and any other relevant factors. Clinical Policy Bulletins Aetna's CPBs describe Aetna's policy determinations of whether certain services or supplies are medically necessary or experimental or investigational, based upon a review of currently available clinical information. Clinical determinations in connection with individual coverage decisions are made on a caseby case basis consistent with applicable policies. Aetna's CPBs do not constitute medical advice. Treating providers are solely responsible for medical advice and for your treatment. You should discuss any CPB related to your coverage or condition with your treating provider. While Aetna's CPBs are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. You and your providers will need to consult the benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. CPBs are regularly updated and are therefore subject to change. Aetna's CPBs are available online at Precertification Precertification is the process of collecting information prior to inpatient admissions and performance of selected ambulatory procedures and services. The process permits advance eligibility verification, determination of coverage, and communication with the physician and/or you. It also allows Aetna to coordinate your transition from the inpatient setting to the next level of care (discharge planning), or to register you for specialized programs like disease management, case management, or maternity management programs. In some instances, precertification is used to inform physicians, members and other health care providers about cost-effective programs and alternative therapies and treatments. Certain healthcare services, such as hospitalization or outpatient surgery, require precertification with Aetna. When you are to obtain services requiring precertification from a participating provider, the provider is responsible to precertify those services prior to treatment. If your plan covers out-of-network benefits and you may self-refer for covered services, it is your responsibility to contact Aetna to precertify those services which require precertification. Refer to your plan documents for specific information. Only medically necessary services are covered. A service or supply furnished by a particular provider is medically necessary if Aetna determines that it is appropriate for the diagnosis, the care or the treatment of the disease or injury involved. Note: If your enrolled in an Aetna Golden Choice Plan, please refer to your plan documents for specific information regarding precertification. Utilization Review/Patient Management Aetna has developed a patient management program to assist in determining what health care services are covered under the health plan and the extent of such coverage. The program assists you in receiving appropriate health care and maximizing coverage for those health care services. You can avoid receiving an unexpected bill with a simple call to Aetna s Member Services team. You can find out if your preventive care service, diagnostic test or other treatment is a covered benefit before you receive care just by calling the toll-free number on your ID card. In certain cases, Aetna reviews your request to be sure the service or supply is consistent with established guidelines and is included or a covered benefit under your plan. We call this utilization management review. We follow specific rules to help us make your health a top concern: Aetna employees are not compensated based on denials of coverage. 6

7 We do not encourage denials of coverage. In fact, our utilization review staff is trained to focus on the risks of members not adequately using certain services. Where such use is appropriate, our Utilization Review/Patient Management staff uses nationally recognized guidelines and resources, such as The Milliman Care Guidelines to guide the precertification, concurrent review and retrospective review processes. To the extent certain Utilization Review/Patient Management functions are delegated to IDSs, IPAs or other provider groups (" Delegates"), such Delegates utilize criteria that they deem appropriate. Utilization Review/Patient Management policies may be modified to comply with applicable state law. Only medical directors make decisions denying coverage for services for reasons of medical necessity. Coverage denial letters for such decisions delineate any unmet criteria, standards and guidelines, and inform the provider and you of the appeal process. For more information concerning utilization management, you may request a free copy of the criteria we use to make specific coverage decisions by contacting Member Services. You may also visit to find our Clinical Policy Bulletins and some utilization review policies. Doctors or health care professionals who have questions about your coverage can write or call our Patient Management department. The address and phone number are on your ID card. Concurrent Review The concurrent review process assesses the necessity for continued stay, level of care, and quality of care for members receiving inpatient services. All inpatient services extending beyond the initial certification period will require concurrent review. Discharge Planning Discharge planning may be initiated at any stage of the patient management process and begins immediately upon identification of post-discharge needs during precertification or concurrent review. The discharge plan may include initiation of a variety of services/benefits to be utilized by you upon discharge from an inpatient stay. Retrospective Record Review The purpose of retrospective review is to retrospectively analyze potential quality and utilization issues, initiate appropriate follow-up action based on quality or utilization issues, and review all appeals of inpatient concurrent review decisions for coverage of health care services. Aetna's effort to manage the services provided to you includes the retrospective review of claims submitted for payment, and of medical records submitted for potential quality and utilization concerns. Medicare Advantage Grievance Process Aetna is committed to addressing members' coverage issues, complaints and problems. If you have a coverage issue or other problem, call Member Services at the toll-free number on your ID card. You can also contact Member Services through the Internet at If Member Services is unable to resolve your issue to your satisfaction, you can request that your concern be forwarded to the Medicare grievance unit, or you may write to the address in your area listed in the Evidence of Coverage. If your issue is regarding a denial of a claim or denial of coverage for a health care service, please refer to the Medicare Advantage Appeals Rights below for more information. Medicare Advantage Appeal Rights As a member of an Aetna Medicare Advantage plan, you have the right to appeal any decision resulting in Aetna's failure to provide coverage for or pay for what you believe are covered benefits and services. These include: Reimbursement for coverage of emergency or urgently needed services, or out-of-area dialysis services. A denied claim for coverage of health care services that you believe should have been reimbursed by Aetna. 7

8 Coverage for an item or service that you have not received but which you believe should be covered. Any decision to discharge you from the hospital if you believe it is too early to do so. (Note: In this case, a notice will be given to you with information about how to appeal to a Medicare Quality Improvement Organization (QIO). You will remain in the hospital while the QIO immediately reviews the decision. You will not be held liable for charges incurred during this period regardless of the outcome of the review. Refer to your Evidence of Coverage for the QIO in your area.) Reduction or terminations of coverage for what you feel are medically necessary covered services. Aetna has a Medicare Advantage Standard Appeals Process and a Medicare Advantage Expedited Appeals Process. Following is a general explanation of these important processes. Assistance With Appeals If you need assistance understanding or following the Medicare Advantage Appeals Process, you can get assistance from a friend, lawyer or someone else. There are also groups, such as legal aid services that can help you find a lawyer or give you free legal services, if you qualify. You may appoint an individual to act as your authorized representative by following the steps below: The individual can be a relative, provider, friend or someone else. (Note: A physician may request an expedited appeal on your behalf without being appointed as your representative.) Give us your name, your Medicare claim number, Medicare identification number and a written statement that appoints an individual as your representative. For example, the following statement will suffice as an appointment of representative: "I {your name} appoint {name of representative} to act as my authorized representative in requesting an appeal from Aetna regarding denial of coverage for requested services and/or payment." You must sign and date the statement. Your representative must also sign and date the statement unless he/she is an attorney. Include the signed statement with your request. Medicare Advantage Standard Appeals Process Aetna must notify you in writing of any decision (partial or complete) to deny a claim or service. The notice must state the reasons for the denial and also must inform you of your right to file an appeal. If you decide to proceed with the Medicare Advantage Standard Appeals Process, the following steps will occur: 1. You must submit a written request for reconsideration to Aetna. Please refer to the Evidence of Coverage for the appropriate address in your area. You must submit your written request within sixty (60) calendar days of the date of the notice of the initial decision. The sixty (60) day limit may be extended for good cause. Please include in your written request the reason you could not file within the sixty (60) day time frame. 2. Aetna will conduct the reconsideration and notify you in writing of the decision, using the following time frames: Request for Services: If the appeal is for a denied service, we must notify you of the reconsidered decision as expeditiously as your health requires, but no later than thirty (30) calendar days from receipt of your request. We may extend this time frame by up to fourteen (14) calendar days if you request the extension or if we need additional information and the extension of time benefits you. Request for Payment: If the appeal is for a denied claim, Aetna must notify you of the reconsidered decision no later than sixty (60) calendar days after receiving your request for a reconsidered decision. Our reconsidered decision will be made by a person(s) not involved in the initial decision. You may present or submit relevant facts and/or additional evidence for review either in person or in writing to Aetna. 8

9 3. If we decide fully in your favor on a request for a service, we must provide or authorize the requested service within thirty (30) calendar days of the date we received your request for reconsideration. If we decide fully in your favor on a request for payment, we must make the requested payment within sixty (60) calendar days of the date we received your request for reconsideration. 4. If we decide to uphold the original adverse decision, either in whole or in part, we will automatically forward the entire file to the MAXIMUS Federal Services Inc. for a new and impartial review. MAXIMUS Federal Services Inc. is the Centers for Medicare & Medicaid Services independent contractor for appeal reviews involving Medicare Advantage managed care plans. We must send MAXIMUS Federal Services Inc. the file within thirty (30) calendar days of a request for services and within sixty (60) calendar days of a request for payment. 5. For cases submitted for review, MAXIMUS Federal Services Inc. will make a reconsidered decision and notify you in writing of the reasons for the decision. If MAXIMUS Federal Services Inc. upholds our decision, their notice will inform you of your right to a hearing before an Administrative Law Judge of the Social Security Administration. If MAXIMUS Federal Services Inc. decides in your favor, we must: Authorize the disputed service within 72 hours from the date we receive notice from MAXIMUS Federal Services Inc. reversing the decision; or Provide the disputed service as expeditiously as your health condition requires, but no later than fourteen (14) calendar days from the date we receive notice from MAXIMUS Federal Services Inc. reversing the decision; or Pay for the disputed service within thirty (30) calendar days from the date we receive notice from MAXIMUS Federal Services Inc. reversing the decision. If MAXIMUS Federal Services Inc. does not rule fully in your favor, there are further levels of appeal: 6. If there is at least $110 in controversy, you may request a hearing before an Administrative Law Judge (ALJ) by submitting a written request to Aetna, MAXIMUS Federal Services Inc. or the entity specified in MAXIMUS Federal Services Inc. reconsideration notice. The request must be sent within sixty (60) calendar days of the date of MAXIMUS Federal Services Inc. notice that the reconsidered decision was not in your favor. This sixty (60) day notice may be extended for good cause. 7. Either you or Aetna may request a review of an ALJ s decision by the Medicare Appeals Council (MAC), which may either review the decision or decline review. 8. If the amount involved is $1090 or more, either you or Aetna may request that a decision made by the MAC, or the ALJ, if the MAC has declined review, be reviewed by a federal district court. 9. Any initial or reconsidered decision made by Aetna, MAXIMUS Federal Services Inc., the ALJ or the DAB can be reopened by any party (a) within twelve (12) months, (b) within four (4) years for just cause or (c) at any time for clerical correction of an error or in cases of fraud. Medicare Advantage Expedited Appeals Process 1. You may file a request for an expedited appeal for the denial of coverage for services you believe you need and where you feel that applying the standard reconsideration process could jeopardize your health. If Aetna decides that the time frame for the standard process could seriously jeopardize your life, health or ability to regain maximum function, the review of your request will be expedited. If you disagree with a decision to discharge you from the hospital, see the next section. 2. A physician may file a request for an expedited appeal on your behalf. Aetna must provide an expedited reconsideration if the physician indicates that applying the standard reconsideration process could seriously jeopardize your life, health or ability to regain maximum function. 9

10 3. Aetna will notify you and/or the physician of its decision as expeditiously as your health condition requires, but no later than 72 hours after receiving the request. We may extend this time frame by up to fourteen (14) calendar days if you request the extension or if we need additional information, and the extension of time benefits you. 4. To request an expedited appeal, you may call You may fax, mail or hand deliver your written request to Aetna. If you write, the 72-hour review time will not begin until your request is received. Please call us for fax/delivery information. 5. If Aetna determines that your request is not timesensitive, where your health is not seriously jeopardized, Aetna will notify you verbally and in writing and will automatically begin processing your request under the standard reconsideration process. If you disagree and believe the review should be expedited, you may file a expedited grievance with Aetna. The written notice will include instructions on how to file a grievance. Hospital Discharges When you are first admitted to the hospital, you will receive a document entitled, "An Important Message from Medicare". Please read this document carefully. It will describe your rights if you believe you are being asked to leave the hospital too soon. You have the right to request a review by a Quality Improvement Organization (QIO) of any discharge decision. If you request the review by noon of the first workday after you receive the discharge decision, you do not have to pay for your hospital care until the QIO makes its decision. If you ask for immediate review by the QIO, you will be entitled to QIO process instead of the Medicare Advantage appeals process. If you choose to utilize your Medicare Advantage appeal rights, you would follow the process described above. Quality-of-Care Complaints You also have the right to complain about the quality of medical services provided by network providers not meeting professionally recognized standards of care by writing to the QIO. The organization must review the complaint and inform you or your representative of the results of the investigation. They can provide information about its review time frames and the steps involved in the process. Refer to your plan documents for the QIO in your area. Medicare Fast Track Appeal Procedure for Skilled Nursing Facility (SNF), Home Health Agency (HHA) or Certified Outpatient Rehabilitation Facility Terminations (CORF) When these services are no longer covered by the plan, you will receive a written notice from the provider at least 2 calendar days in advance of termination of coverage. You or your authorized representative may be asked to sign and date the notice, which outlines your rights. Signing the notice does not mean that you agree that coverage should end. It only means that the notice was provided. As explained in the advance written notice, you have the right to request a fast appeal of the termination of coverage. The fast appeal will be performed by the Quality Improvement Organization (QIO). The advance written notice you receive from the provider will give the name and telephone number of the QIO. When the QIO reviews your case, they will look at the medical information. The QIO will then give an opinion whether your coverage for services will be terminated on the date that has been provided in the advance written notice. The QIO will make this decision within one full day after they receive the information needed to make a decision. If you ask for a fast track appeal from the QIO, they must make the request according to the following: If the notice is given 2 days before the coverage ends, the request should be made no later than noon of the day after the provider gave the notice. 10

11 If the notice is given more than 2 days before the coverage ends, the request should be made no later than noon the day before the date the Medicare coverage ends. If the QIO decides that the decision to terminate coverage was medically appropriate, you will be responsible for paying the SNF, HHA or CORF charges after the termination date on the advance written notice you received from the provider. If the QIO agrees with you, then the plan will continue to provide coverage for the SNF, HHA or CORF services for as long as medically necessary. If you do not request the QIO to do a fast track appeal of the discharge by the deadline, you can ask the plan for an Expedited/72-Hour review under the Medicare Advantage Expedited Appeals Process. Member Rights & Responsibilities You have the right to receive a copy of our Member Rights and Responsibilities Statement. This information is available to you online at You can also obtain a print copy by contacting Member Services at the number on your ID card. Member Services To file a compliant or an appeal, for additional information regarding copayments and other charges, information regarding benefits, to obtain copies of plan documents, information regarding how to file a claim or for any other question, you can contact Member Services at the toll-free number on your ID card, or us from your secure member website, Aetna Navigator at Click on Contact Us after you log in. When you require assistance from an Aetna representative, call us during regular business hours at the number on your ID card. Our representatives can: Answer benefits questions Help you get referrals Find care outside your area Advise you on how to file complaints and appeals Connect you to behavioral health services (if included in your plan) Find specific health information Provide information on our Quality Management program, which evaluates the ongoing quality of our services Interpreter/Hearing Impaired Interpreter Aetna can help explain benefit and provider information in up to 140 languages! If you require Spanish speaking assistance, please contact us at the toll free number located on your ID card and follow the prompts. If you require assistance in a language other than Spanish please call us at the toll free number that is located on your ID card and ask for an interpreter. Hearing Impaired TDD: (hearing impaired only) Quality Management Programs Call Aetna to learn about the specific quality efforts we have under way in your local area. Ask Member Services for the phone number of your regional Quality Management office. If you would like information about Aetna Behavioral Health s Quality Management Program, ask Member Services for the phone number of your Care Management Center Quality Management office. Privacy Notice Aetna considers personal information to be confidential and has policies and procedures in place to protect it against unlawful use and disclosure. By personal information, we mean information that relates to your physical or mental health or condition, the provision of health care to you, or payment for the provision of health care to you. Personal information does not include publicly available information or information that is available or reported in a summarized or aggregate fashion but does not identify you. When necessary or appropriate for your care or treatment, the operation of our health plans, or other related activities, we use personal information internally, share it with our affiliates, and disclose it to health care providers (doctors, dentists, pharmacies, 11

12 hospitals and other caregivers), payors (health care provider organizations, employers who sponsor selffunded health plans or who share responsibility for the payment of benefits, and others who may be financially responsible for payment for the services or benefits you receive under your plan), other insurers, third party administrators, vendors, consultants, government authorities, and their respective agents. These parties are required to keep personal information confidential as provided by applicable law. Participating network providers are also required to give you access to your medical records within a reasonable amount of time after you make a request. Some of the ways in which personal information is used include claims payment; utilization review and management; medical necessity reviews; coordination of care and benefits; preventive health, early detection, and disease and case management; quality assessment and improvement activities; auditing and anti-fraud activities; performance measurement and outcomes assessment; health claims analysis and reporting; health services research; data and information systems management; compliance with legal and regulatory requirements; formulary management; litigation proceedings; transfer of policies or contracts to and from other insurers, HMOs and third party administrators; underwriting activities; and due diligence activities in connection with the purchase or sale of some or all of our business. We consider these activities key for the operation of our health plans. To the extent permitted by law, we use and disclose personal information as provided above without your consent. However, we recognize that you may not want to receive unsolicited marketing materials unrelated to your health benefits. We do not disclose personal information for these marketing purposes unless you consent. We also have policies addressing circumstances in which you are unable to give consent. To obtain a hard copy of our Notice of Privacy Practices, which describes in greater detail our practices concerning use and disclosure of personal information, please write to Aetna's Legal Support Services Department at 151 Farmington Avenue, W121, Hartford, CT You can also visit our Internet site at You can link directly to the Notice of Privacy Practices by Plan Type, by selecting the "Privacy Notices" link at the bottom of the page, and selecting the link that corresponds to your specific plan. 12

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14 Additional Important Disclosure Information Aetna Golden Medicare Plan Only Please Read 14

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16 Additional Important Disclosure Information Aetna Golden Medicare Plan Only Cost Sharing You are responsible for any copayments, coinsurance and deductibles for covered services. These obligations are paid directly to the provider or facility at the time the service is rendered. Copayment, coinsurance and deductible amounts are listed in your benefits summary and plan documents. Role of Primary Care Physicians ("PCPs") For most Aetna Medicare HMO plans, you are required to select a PCP who participates in the network. The PCP can provide primary health care services as well as coordinate your overall care. You should consult your PCP when you are sick or injured to help determine the care that is needed. Your PCP should issue referrals to participating specialists and facilities for certain services. For some services, your PCP is required to obtain prior authorization from Aetna. Except for those benefits described in the plan documents as direct access benefits, plans with self-referral to participating providers (Aetna Open Access or Aetna Choice POS), plans that include benefits for nonparticipating provider services (Aetna Choice POS or QPOS), or in an emergency, you will need to obtain a referral authorization ("referral ") from your PCP before seeking covered nonemergency specialty or hospital care. Check your plan documents for details. Referral Policy If your plan documents state referrals are required, please review the following important points regarding referrals. The referral is how your PCP arranges for you to be covered for necessary, appropriate specialty care and follow-up treatment. You should discuss the referral with your PCP to understand what specialist services are being recommended and why. If the specialist recommends any additional treatments or tests that are covered benefits, you may need to get another referral from your PCP prior to receiving the services. If you do not get another referral for these services, you may be responsible for payment. Except in emergencies, all hospital admissions and outpatient surgery require a prior referral from your PCP and prior authorization by Aetna. If it is not an emergency and you go to a doctor or facility without a referral, you must pay the bill. Referrals are valid for one year as long as you remain an eligible member of the plan; the first visit must be within 90 days of referral issue date. In plans without out-of-network benefits, coverage for services from nonparticipating providers requires prior authorization by Aetna in addition to a special nonparticipating referral from the PCP. When properly authorized, these services are fully covered, less the applicable cost-sharing. The referral provides that, except for applicable cost sharing, you will not have to pay the charges for covered benefits, as long as the individual seeking care is a member at the time the services are provided. Emergency Care If you need emergency care, you are covered 24 hours a day, 7 days a week, anywhere in the world. An emergency medical condition is one manifesting itself by acute symptoms of sufficient severity such that a prudent layperson, who possesses average knowledge of health and medicine, could reasonably expect the 16

17 absence of immediate medical attention to result in serious jeopardy to the person's health, or with respect to a pregnant woman, the health of the woman and her unborn child. Whether you are in or out of an Aetna Golden Medicare plan service area, we simply ask that you follow the guidelines below when you believe you need emergency care. Call the local emergency hotline (ex. 911) or go to the nearest emergency facility. If a delay would not be detrimental to your health, call your PCP. Notify your PCP as soon as possible after receiving treatment. If you are admitted to an inpatient facility, you or a family member or friend on your behalf should notify your PCP or Aetna as soon as possible. What to Do Outside Your Aetna Golden Medicare Plan Service Area If you are traveling outside of your Aetna Golden Medicare Plan service area, you are covered for emergency and urgently needed care. Urgent care may be obtained from a private practice physician, a walk-in clinic, an urgent care center or an emergency facility. Certain conditions, such as severe vomiting, earaches, sore throats or fever, are considered urgent care" outside your Aetna Golden Medicare Plan service area and are covered in any of the above settings. If, after reviewing information submitted to us by the provider that supplied care, the nature of the urgent or emergency problem does not qualify for coverage, it may be necessary to provide us with additional information. We will send you an Emergency Room Notification Report to complete, or a Member Services representative can take this information by telephone. Follow-up Care after Emergencies All follow-up care should be coordinated by your PCP. Follow-up care with nonparticipating providers is only covered with a referral from your PCP (when required by your plan) or prior authorization from Aetna. Whether you were treated inside or outside your Aetna Golden Medicare Plan service area, if your plan requires referrals, you must obtain a referral before any follow-up care can be covered. If your plan does not require referrals you should contact Aetna at the number on your ID card before care is received at nonnetwork facilities. Suture removal, cast removal, X-rays and clinic and emergency room revisits are some examples of follow-up care. After-Hours Care You may call your doctor s office 24 hours a day, 7 days a week if you have medical questions or concerns. You may also consider visiting participating Urgent Care facilities. How Aetna Compensates Your Health Care Provider All the physicians are independent practicing physicians that are neither employed nor exclusively contracted with Aetna. Individual physicians and other providers are in the network by either directly contracting with Aetna and/or affiliating with a group or organization that contract with us. Participating providers in our network are compensated in various ways: Per individual service or case (fee for service at contracted rates). Per hospital day (per diem contracted rates). Capitation (a prepaid amount per member, per month). Through Integrated Delivery Systems (IDS), Independent Practice Associations (IPA), Physician Hospital Organizations (PHO), Physician Medical Groups (PMG), behavioral health organizations and similar provider organizations or groups. Aetna pays these organizations, which in turn may reimburse the physician, provider organization or facility directly or indirectly for covered services. In such arrangements, the group or organization has a financial incentive to control the cost of care. One of the purposes of managed care is to manage the cost of health care. Incentives in compensation arrangements with physicians and health care providers are one method by which Aetna attempts to achieve this goal. 17

18 In some regions, the PCP can receive additional compensation based upon performance on a variety of measures intended to evaluate the quality of care and services the PCP provides to you. This additional compensation is typically based on the scores received on one or more of the following measures of the PCP's office: member satisfaction, percentage of members who visit the office at least annually, medical record reviews, the burden of illness of the members that have selected the primary care physician, management of chronic illnesses like asthma, diabetes and congestive heart failure; whether the physician is accepting new patients; and participation in Aetna's electronic claims and referral submission program. Some regions may use some different measures designed to enhance physician performance or improve administrative efficiency. You are encouraged to ask your physicians and other providers how they are compensated for their services. 18